The thoughts of a nurse with type 1 diabetes

Menu

Tag Archives: informatics

For the last decade, or so it seems, in my professional technology life, we have been talking about the holy grail of interoperability. So, what on earth does that mean? I’m basically a non-techie and my understanding of interoperability is that we can send information around the system, from one place to another, and when it sets off it doesn’t lose any meaning as its transferred and arrives with its meaning intact. In other words, the information is available and understood by the person that receives it and this is as the sender intended. Standards are key to making this happen and at last this is starting to happen. Have a look at the PRSB and Interopen.
Wow, I mean that means we can share information using standards and free up information that have traditionally been effectively locked behind electronic walls.

Freeing up information to flow around the system comes with some issues and in our endeavours to make it flow I am not sure we have thought through some of the consequences of all this data arriving at the point of care, in a multi-professional context, that centres around the care of an individual person.

Back in the olden days, when I was a ward sister and subsequently investigating complaints, I was often faced with large piles of paper notes about an individual patient. They were hard to plough through. There were some tricks that everyone used to use to get to the essence of what had been happening to a patient. At the back of the notes there were, usually in reverse date order, a set of correspondence between different doctors; an admission referral, a discharge summary, letters from clinic and so it went on. That’s where you started to get the best picture, a timeline, of what had been going on.

I know that we are working on standards that provide similar summaries of episodes of care which is brilliant. They will provide a much-needed way of navigating a person’s care in a timeline.

The challenge comes for those areas and professions who may be less practiced and used to summarisation; nursing for example.There is a risk that all this machine processable information will flow into records (maybe alongside information sent by patients too) and we won’t be able to see the wood for the trees! Imagine if you had to review every piece of information in one of those fat sets of paper notes and you were on a busy MAU. It will be like the quote from Mitchell Kapor: ‘Getting information of the internet is like drinking from a fire hydrant’. How will we ever know what is important and what can be left?
Some professionals already have solved this problem or at least started to do so. GPs, the most experienced Health Care Professionals in using electronic records, already understand the value of summaries and lists but these operate in one environment only.

How are we going to prevent this information that will be flowing around systems becoming overwhelming? How will we make it so that clinical staff do not feel the need to review every piece of information? Where will we stand if we fail to review once piece of information amongst the many?

It seems to me that we might need to think about a longitudinal record for a citizen and stop seeing records as a patchwork of systems connected by standards. If we fail to summarise, to prioritise, and to recognise that everyone can’t read everything, how are we going to sort out the most useful information from the most mundane? How can machine processing help us (or can it)? How will we share the piles of data across all the professions?

What I do know is that this affects the way nurses and probably others need to think about the way we keep records. If we don’t we will drown in a deluge of electronic information and potentially be no better off than we are today.

Perhaps we can just let the citizen take responsibility for the timeline? But that probably won’t work for everyone.

The essence of the session I presented at #NIPEC18 today

Are you digitally ready? I am hoping I am!

Maybe you are expecting a technical presentation; this is not that. That’s because I actually believe that this whole agenda is about people. Its not about a list of technical capabilities – its about how people respond to technology and its about everyone in this room, so how do you know if you are digitally ready?

First of all, for context, I would like to reflect back.

Its 1983 and I am a fresh faced student nurse. Much of the technology we have now didn’t even seem possible then. We had no mobile phones and as a patient I was boiling my insulin syringe in a pan in the kitchen.

Over the decades since then I have assimilated technology into both my professional and my personal life, as I am sure you have too.

I have had no training in any of these things but I bank online, I order my meds online, I look loads up on google, I have an insulin pump and a Continuous Glucose Monitor. I love the connections I gain on social media and I use this in both my social and professional life.

I feel I am digitally ready in many senses.

But what is it exactly that makes me so?

Here are the 5 characteristics that I think make me digitally ready:

The first is that I am change positive; that is I have a positive professional orientation towards change, seeing it as an opportunity rather than something to be avoided. I like doing novel things. I was the first complaints manager at our Trust, I was part of the team that set up NHS Direct, a nurse led telephone triage service and I think was one of the early nurses to work in an informatics role. I experiment (safely of course) all the time, like I am experimenting today with you, presenting without slides. You will have to let me know how it goes!

For me being change ready means exactly that, prepared to try new things, experiment and play.

I believe that all nurses need to be change positive as nursing as its taught today is unlikely to be the nursing of the future. The pace of change is ramping up and technology is a large part of that, for example genomics and personalised medicine is likely to be come a reality in my lifetime.

I have already seen significant professional change. I used to be a staff nurse on a cadiology ward. The only way we could do surgery on someone’s lungs was a large incision in someone’s chest. It took days for them to recover. It was painful. Now, today they can do this type of surgery using keyhole surgery. Think of the massive difference it makes. It improves recovery but just think about the changes it makes to caring for these people! It shifts the focus for nursing too. And I predict it will be robotics next.

Being change ready is a good life skill as well as a professional skill too!

The second trait is Curiosity, when I mentor people I always advise them to remain curious.

Curiosity drives progress. If we are not interested in ‘what if’ then things will always stay the same.

Curious people can be intimidating though – they challenge the status quo and make people feel uncomfortable. I have often asked developers difficult questions about the art of the possible and hopefully driven better outcomes for patients as a result. Its part of being able to see a wider perspective and to be able to see how technology and data can be used to a fuller strategic perspective.

So what am I currently curious about? If we want to care for more people at home how can we lever technology to help? I visited a brilliant care home near Coventry last week where these are using noise detectors in a large home to help to identify when things happen at night. This increases rather than decreases privacy as it prevents the night staff having to actually go in to rooms at night for checks which in turn frees them up to support people who don’t sleep and focus on their ‘Wide awake club’ meaning care overall improves (and falls have reduced too). I am interested in technology like Alexa and exploring how we can use it with patients. Artificial intelligence too……. I could go on…… technology is a rich seam of interesting stuff for a curious person.

Curious people often have great imagination too and can describe how things might be, having conversations, visioning, and leading strategic change.

The third trait is a relentless focus on improvement.

I care deeply about the experience of people we care for, their carers and families. This is fed from my own long term condition but everyone has the potential to empathise.

Sometimes the status quo is fine when you are on the right side of the service. But it might be less so when you or your loved ones are unwell. It changes the dynamic and you suddenly have what I call ‘real skin in the game’.

An example:

This week I received a letter from my GP. It pointed out that I have a prescription for pre-filled insulin pens but I have no prescription for needles and it enclosed a leaflet on how to give injections. It concluded that they had set up an prescription for me to have needles.

What they failed to do was check my record.

The data they hold about me should have told them that I have an insulin pump. I only use pens as a back up and rarely use them. I have a box of 100s of needles prescribed 10 years ago that I have yet to use.

If the people focused hard on improvement using data they would have realised a number of things:

I am a pump user so don’t need many needles

I have had diabetes since 1979 and maybe sending me a leaflet about giving injections was slightly patronising (I suspect I have given more injections than the practice nurse).

I think using data is an important part of improvement science. But use it well. Focus on outcomes and do proper PDSA cycles.

I would love to know what outcome they expected when they sent me the letter.

Improving my injection technique might be the aim and I am grateful for that but they need to use the data in a better way.

Data is the lifeblood of improvement science.

If they wanted to make things better what outcome are they measuring? And how will they judge if they have made a difference.

Nurses who are digitally ready focus on service improvement informed by data! I can’t stress strongly enough that a digital ready nurse understands the value of data and the contribution it makes to better outcomes.

My fourth point is resilience. Its quite a trendy word right now so what exactly do I mean?

Resilient people keep trying. They are bouncy and in this instance keep advocating for the technology no matter how many times they are shouted down or doors slammed in their faces. When you innovate using technology it doesn’t always go well but you have to keep adjusting, reframing until you get the best outcomes.

Its OK to say ‘That didn’t work did it? Now how can we try to make it better?’ It takes a particular tenacity and resilience to safely fail and keep trying. It’s a mind set. I suppose another word for this might be an optimistic mindset.

I honestly think that technology and data create a great opportunity to make the lives of patients and nurses better. But it’s a journey. Its not a one off. It takes hard work, as an ongoing endless journey.

I have been in this space for 17 years and I have often felt like I was talking to myself.

Things are changing but digital nurses need to not fall over at the first hurdle but believe data and technology CAN make things better.

Finally trait five!

Networking and learning from each other.

I believe in stealing other peoples good ideas and building on them, if it improves care. I don’t mean stealing patents, and those type of ideas, but I do mean the sort of mentality that looks around to see what other people are doing to see what you can learn!

Social media is one way of doing this. Digital in this sense has created a whole new way of learning and communicating across the world.

Networks are a fantastic way to feed your curious traits, or your creative skills. I urge you to connect and look around. Are you well connected? Do you have fantastic networks?

I am lucky that I am often these days asked to judge awards. It shocks me how often nurses describe their projects to us and see them as unique, special – when in fact the trust in the next county or in NI or Scotland or wherever, are doing the same thing better! Just think of the potential of networks when they are cumulative for the development of ideas.

Networks are generous spaces; if you don’t believe me take a look at the Fab NHS Stuff site where people are generously sharing their ideas.

So, finally – why do I think I might be digitally ready?

The five characteristics:

I am change positive, curious and relentlessly focussed on improving the experience of service users and importantly outcomes. I am resilient, prepared to try new things and learn from others.

When I was 26 I decided that I wanted to do a different nursing role and I became a research nurse for a programme that aimed to develop an quality of life assessment tool. I don’t think you can do much more patient centred work than this but despite that my father-in-law told me that I had ‘sold my soul’ and all ‘proper’ nurses were at the bedside and I was wasting the money that had been invested in my training. This was an ongoing debate between us but essentially I ignored him. This wasn’t the last time similar things would be said to me in my career. Later when I went to help to set up the NHS Direct service I was told by other nurses that I had ruined my career and I would never get another job. It was clear to me that for my father-in-law and for these other people the professional identity of a nurse was firmly uniformed and at the bedside.

I recently read an interesting paper that seeks to understand issues of professional identity for medical professionals who have adopted a managerial leadership role. This strikes me as in many ways like a nurse who has moved into new professional contexts away from the bedside. I thought it would be interesting to use the framework identified in this work for personal reflection on my career and professional identity as a nurse, manager and informatics specialist. Be prepared! If you read the whole paper I found it a hard read, reaching as it does into sociology and organisational theory.

So here it is – I will try to summarise what I see as the key points from the paper. I have taken the key conceptual points but not dived into the full conceptual framework (I suspect that would be a PhD!).

The first role identified is doctors who are described as ‘incidental hybrids’, those who find themselves in positions of management responsibility but do this through a sense of responsibility or duty. They are likely to maintain strong personal professional identity, continuing to see themselves principally as part of their professional group, managing the same traditional professional individual and group norms. They usually position themselves in these roles in a transitory way often by obligation. These types of clinical managers usually represent and protect institutionalised professionalism. They seek to align themselves to their professional identity and group first and may down play the managerial aspects of their role. They are likely to adopt a ‘representation’ position in relation to their profession.

In contrast, ‘willing hybrids’ are those professionals who have adopted and integrated a broader professional identity earlier in their careers or later in response to professional identity challenges; they have thought through the breadth of professionalism and see it extending beyond that of the traditional model and have embraced this identity. They have a different professional narrative to a traditional one, often formed by mentors and role models, where they have identified and sought to resolve professional identity conflicts and embrace the hybrid role. An example of this might be the tension between the attention to a single patient versus the needs of a population, weighing up the collective good versus individual need or where there is a need for professionals to align themselves with managers rather than seeking purely a professional allegiance. Willing clinical managers often position themselves as a professional elite seeing the management of others and/or services as a more challenging role. These are professionals who have embraced a permanent hybrid state. They are likely to be misaligned with traditional models of professionalism by engaging with others outside of the traditional professional hierarchy, for example managers, to the extent that others may accuse them of ‘moving to the dark side’.

I found this article to be really thought provoking making me reflect on my role in relation to nursing professionalism and my career.

Through my career I have sought managerial roles where the impact of what I do extends beyond that of individual patients and have been accused in the past of having ‘sold my soul (to management)’ and yet I still feel firmly placed in a nursing professional context. I think I have managed to reconcile my adopted roles and integrate these with my professional identity. Early in my career I admired nurses who were visible change agents, doing new things and leading us to new thinking. My move to being a hybrid professional came reasonably early in my career.

My extension of thinking around the contribution of nursing and the broader professional agenda was influenced by people in novel and innovative roles. Two examples spring to mind: Alison Kitson who I met in the late 80s/early 90s when she was working on standards of care – I so wanted to work on similar creative and innovative work. Similarly, in the early 1990s I went to Leicester Royal Infirmary and met Helen Bevan (@helenbevan) who was then leading innovative service improvement initiatives – I can remember wanting exactly that job. It’s funny but I now know Helen and although my visit is very memorable to me I know she can’t remember it! Finally in the early 2000s I was very inspired by Maxine Craig (@maxine_craig) who was a nurse who had already taken a step towards a realignment of her professional identity and I was in awe of the improvement work she was doing and again I remember thinking I really wanted her job! Of course I never did get any of those service improvement roles despite trying – sometimes its being in the right place at the right time!

I still feel hurt when others make the observation that I am ‘no longer a real nurse’ as in my reflection of professional and personal identity I believe that it is possible to both be a nursing professional but one whose role extends beyond that of direct patient care. I see this accusation as similar to those who accuse doctors in management as having moved to the ‘dark side’.

My reflection is that nurses who work in informatics or technology roles also have adopted hybrid professional roles where there is the necessity to blend professional identity and influence change at scale, including influencing what we might consider to be out-dated and old-fashioned professional nursing practices.

I can also see how this is challenging and why professionals with these blended professional identities seek to join a new professional tribe, where the issues of professional identity management and norms can be more safely explored. These tribes also create alternative role models and mentors. I feel that this is emerging in the informatics community where they have even selected to embark on a journey of professionalisation.

My conclusion is that I have a tendency toward being a willing hybrid who elected to adopt a role that seeks to combine professional identity to a specialist informatics role. I believe that it is possible to hold the values of patient driven care at a population level beyond that of meeting the needs of an individual patient.

The paper discusses in more detail the impact of hybrid professionals and identity work and I recommend it as reading in particular for those who find themselves in non-traditional professional roles.

Thanks to Pete Thomond (@pete.Thomond) , Managing Director, CleverTogether, for bringing this paper to my attention but also for his analysis of the paper which helped to form my reflections.

I believe that the phrase ‘Once a nurse, always a nurse!’ is true but it is possible to adopt a hybrid professional identity; these hybrid roles, that push the boundaries of traditional professionalism, create the climate for professional tensions that lead to change, modernisation and improvement.

Going to the hospital always frustrates me but it is an opportunity to watch – people and processes, communication and clues on culture.

I’m actually writing this sat patiently in the waiting area – we have just been told the clinic is running more than an hour late. So I watch people come and people go.

Last time I was here I wrote a blog about information governance, about how, when you arrive in clinic, you have to declare all your personal details to the full waiting room. I did give them this feedback by the way and I also recognize the challenges in the clinic area. Today the same ritual continues.

[pause – I’ve been in to see the doctor who was lovely. But I’m back for another wait…. so I continue…..]

I am not sure that declaring your personal identifiable information in public is best IG culture.

The next thing made me smile. A man with a big trolley arrives in the clinic. The trolley is piled with notes – over it is a sheet. He gallantly throws it back to reveal and remove a set of notes. Then back again when he is done. Either he is keeping the dust off or he is trying to protect them from view. I gaze on as people adjacent to him continue to declare their full name, address, date of birth and GP including the GPs address!

Meanwhile I overhear someone near me, after seeing the man with the notes tell a story: ‘eeee*’ says the lady to her (assumed) daughter: ‘you will never guess what they told me about my notes?’ The daughter asks for more information. She continues ‘they parceled mine up into a brown paper bag and sealed it with tape when I was going for my scan. I asked them why. They are MY notes after all. She told me they sealed them so I couldn’t open them as they could charge me £15 to look at my notes. This was to stop me looking at them!’